Abstract

Compared to males in almost any social group in all affluent nations, Australia's Aboriginal and Torres Strait Islander men suffer from substantially more serious illnesses and early death. To date, research done by or in collaboration with Indigenous communities has revealed the extent of the problems that arise from diabetes, heart disease, hypertension, cancers, respiratory diseases, psychological disorders, accidental injuries, violence and other causes. Reproductive health, however, rarely has been studied among Indigenous men. To date, research in this field has been limited mainly to studies of sexually transmitted infections. No data has been published on Aboriginal men's symptoms of prostate disease or erectile dysfunction, nor has the clinical screening and treatment of these disorders among these men been assessed. In-depth search of the worldwide web demonstrated that little information on these issues was available from other Indigenous populations. It does appear that Indigenous men in Australia, New Zealand and North America are less likely than European-ancestry men to die from prostate cancer, or for living cases to be recorded on cancer registries. This may arise because Indigenous men genuinely have a lower risk, or because they are not captured by official statistics, or because they do not live long enough to develop severe prostate disease. We also know very little about other reproductive health problems such as sexual dysfunction and specifically erectile difficulties. One reason for our scant knowledge is that research mainly relies on self-report of sensitive information. The aim of the research study was to improve the understanding of sexual and reproductive health problems experienced by Indigenous men. This is best gathered by Aboriginal males who are inside the culture of middleaged and older Indigenous men, but until now this has not been attempted. In this study we adopted the World Health Organization (WHO) definitions for Reproductive and Sexual Health (WHO, 2001). Thus, we consider reproductive system disorders (prostate disease, erectile dysfunction) and related health care-seeking, and also men's perceptions about a "satisfying and safe sexual life". The methodology was framed within an Aboriginal and Torres Strait Islander research protocol that advocates respect for cultural, social and community customs. A mixed method design combined qualitative inquiry (4 focus groups and 18 in-depth interviews) and quantitative survey (n=301) involving men living in remote, rural and urban communities (Tiwi Islands, Darwin and north and south-east Queensland). Survey data were compared to recently published self-reports from 5990 randomly selected men aged over 40 years in Australia (Holden et al., 2005, The Lancet, 366, 218-224. The qualitative interviews revealed that most men were silent about reproductive health. They were unwilling to reveal their inner feelings to wives or partners, and they were unwilling to discuss such issues with doctors and other health care workers. Men's reaction to sexual difficulties included shame, denial, substance abuse and occasionally violence. On a positive note many men said they want to learn about it, so they understand how to cope with such problems. The Indigenous men reported symptoms of erectile dysfunction at least as much as non-Indigenous men in other Australian studies. Bivariate analysis showed that erectile dysfunction was correlated with many health and lifestyle variable. However multivariate analysis revealed that only three factors significantly predicted ED: presence of chronic disease, presence of pain when working, and living in a remote geographic location The quantitative survey data indicate that Indigenous men have more symptoms of prostate disease than non-Indigenous men. The syndrome appears to be poorly managed in clinical practice (e.g. rates of PSA testing and digital-rectal examination are only one-third the rate reported by non-Aboriginal men, despite equivalent likelihood of GP visits). The research study adds to the literature by providing better insight and depth into the issues impacting on Aboriginal and Torres Strait Islander males experiencing reproductive and sexual health difficulties. It also provides a platform to undertake comprehensive research with Aboriginal and Torres Strait Islander men to explore a wider spectrum of questions in this important but neglected area. Implications for education of primary healthcare workers and community-based awareness campaigns for Indigenous males are discussed. Most of all, this study revealed "layers" of silence around sexual and reproductive health of Indigenous men. This includes silence in the scientific establishments in health services, and in the community. It is hoped that this study puts the voices of the men forward to help to break down this silence.

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